Revision: AMS LGX to CX (Dr Loh-Doyle, USC)

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I'm still healing, but finally transferred to home. Been having to take a combo of antibiotics, stool softeners, and norco. There's a gnarly scar where the stitches are now and I can only move certain angles without pain.

Here's the chaos down below:

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I just had a look at the post-op notes from Dr Loh-Doyle regarding my 3rd surgery, which was considered a medical emergency just as the second one was. Thought it'd be an interesting read for some of you as it highlights risks of any surgery, and you definitely want to be with not only a good implant surgeon, but a good medical team as a whole that'll look out for you with care.

SURGEON'S NOTES

SURGEON: Jeffrey Loh-Doyle, MD
CO-SURGEON: Stuart Boyd, MD
ASSISTANT: _____ Mohideen, MD
PREOPERATIVE DIAGNOSIS: Risk of recurrent scrotal hematoma after exchange of the penile prosthesis with active bleeding.
POSTOPERATIVE DIAGNOSIS: Risk of recurrent scrotal hematoma after exchange of the penile prosthesis with active bleeding.
OPERATIVE PROCEDURE:
1. Scrotal exploration.
2. Evacuation of scrotal hematoma.
3. Wound washout.
4. Complex wound closure.
INDICATIONS FOR PROCEDURE: Mr. _____is a 33-year-old male whom I took to the operating room yesterday for removal and replacement of a penile prosthesis. Postoperatively, he was found to have an expanding hematoma in the scrotum and I explored
him yesterday shortly after his original surgery. Interestingly, after both operations, the wound bed was completely pristine and dry. Last night we were contacted at approximately 2:00 a.m. by the nursing team because his scrotum was enlarging in size and
his drain outputs were increasing. Hemoglobin and hematocrit revealed acute blood loss.

I came in and saw the patient with a resident and we found that the scrotum was enlarged and we had a very high suspicion for active bleeding. As a result, we transfused the patient with 2 units of PRBCs as well as 2 units of FFP. We then made arrangements to take the patient back again to the operating room today for exploration, washout, and evacuation of the hematoma. Throughout this process, the patient
was very well informed of our thought process and was willing to proceed with this necessary and critical surgery. I had also enlisted the help of my colleague, Dr. Stuart Boyd to come in as well and we made arrangements for him to be brought to the
operating room this afternoon.

PROCEDURE: The patient was taken to the operating room and after adequate induction of general anesthesia, he was placed in the supine position. He was prepped and draped in the usual sterile manner. On physical exam, the patient had a very tense scrotum. There was also sanguineous output from the drain. The patient's penis, scrotum, and abdomen were all prepped with Betadine as well as ChloraPrep. Rather than going through his infrapubic incision, we wanted to get better exposure to the scrotum where we presumed the active bleeding was from. We made a 6 cm vertical incision just lateral to the penis that extended from the inguinal zone into the anterior scrotum.

Through that incision, we then copiously irrigated and removed a tremendous amount of old blood clot. Approximately 300 mL of old hematoma was removed.

At this point, with the hematoma removed, we then copiously irrigated the scrotum with IrriSept. At this point, we then systematically examined the entire contents of the scrotum. We again delivered the testicle out through our scrotal incision. We examined the cord structures, which we had performed a small ligation on yesterday and the cord itself was noted to be very healthy and pristine and the testicle itself was very viable. There was no active bleeding whatsoever seen on the entire extent of the cord. The pump was removed from the scrotum.

We then examined the underlying scrotal wall. We saw that there was maybe a small little bleeder towards the midline septum of the scrotum. What was surprising was that there was no active bleeding that would explain this tremendous blood loss that the patient experienced. Nevertheless, we used electrocautery to cauterize the medial and lateral scrotal wall. We then packed the wound with Ray-Tecs. After 5 minutes, we then removed the Ray-Tecs and found that there was no active bleeding whatsoever. The wound bed was completely dry and pristine. We then irrigated the wound again with IrriSept. We then applied fibrillar as well as FloSeal to the scrotum as well as to the spermatic cord. There was no blood pooling at all or no fresh oozing from the infrapubic incision zone.

At this point, we then put the testicle back into its native location in the scrotum. We then placed the drain back in place. Then lastly, we placed the pump back into the scrotum. Again, the pump was copiously irrigated with IrriSept. Again, the entire wound was completely dry and there was no active bleeding whatsoever. We then reapproximated the wound in multiple layers, the first layer being 2-0 PDS suture, the second layer being 3-0 Monocryl suture, and the last layer being 4-0 Monocryl suture.

The wound was dressed with Steri-Strips and Mastisol. The Blake drain was then placed back to the suction. A 16-French Foley catheter was placed easily with clear return of urine. We then placed a very compressive dressing on the scrotum that included multiple Kerlix fluffs as well as compressive dressings onto the incisions. This terminated the procedure. There were no on-table complications.
ESTIMATED BLOOD LOSS: 300 mL of old coagulated blood.

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Below pretty much sums up what went on and where I currently am. Still not out of this yet.

DISCHARGE NOTES
Admission Diagnosis: Malfunction of inflatable penile prosthesis
Discharge Diagnosis: Malfunction of inflatable penile prosthesis, Scrotal hematoma
Discharge condition: stable
Procedure performed: Removal and replacement of inflatable penile prosthesis on 9/27/2023
Exploration of the infrapubic wounds with washout and evacuation of hematoma, Ligation of arterial bleed on spermatic cord, Complex wound closure on 9/27/2023
Scrotal exploration, Evacuation of scrotal hematoma, Wound washout, Complex wound closure on 9/28/2023

Brief HPI:
This is a 33-year-old male with history of arterial insufficiency erectile dysfunction, with poor response to oral therapeutics. Patient therefore underwent plantation of an inflatable penile prosthesis on 2/15/2022. It was then noted that the penile implant had begun to lose pressure during intercourse. The patient felt that his device was no longer holding pressure, and he often has to use the pump
and press it during intercourse. The patient presents for removal and replacement of his device and is also hoping to have more stable cylinders placed. The risks and benefits were discussed in depth and the patient was in agreement with the plan. Patient
therefore underwent surgery as indicated above.

Hospital Course:
Postoperatively the patient was admitted to the floor for recovery. On the evening of postoperative day 0, the patient was found by attending surgeon with having pale apperance and significantly enlarged scrotum. Due to concern for large hematoma and active bleeding, the patient was brought to the operating room for Exploration of the infrapubic wounds with washout and evacuation of hematoma, Ligation of arterial bleed on spermatic cord, Complex wound closure on 9/27/2023 (*intraoperative findings included large volume scrotal hematoma, active arterial bleeding of spermatic cord).

On the early morning of 9/28/2023, on-call urology service was contacted by nursing due to increased scrotal swelling as well as output of 200 cc from the Blake drain. Attending surgeon and urology resident evaluated patient in which the patient was noted to have scrotal swelling that appeared to be enlarged compared to when the patient left the operating room for his hematoma evacuation. The Blake drain was emptied in which there appeared to be a slow ooze coming from it. The patient's vital signs were noted to be stable, hemoglobin was noted with slight drift.

Given the patient's clinical picture, decision was made to transfuse patient 2 units of packed red blood cells and 2 units of fresh frozen plasma. The
patient was then taken back to the OR on 9/28/2023 for Scrotal exploration, Evacuation of scrotal hematoma, Wound washout, Complex wound closure. Output from the Blake drain was subsequently noted to be minimal, and scrotum appeared to be softer. CBC and vital signs were also noted to be stable. Patient was treated with IV antibiotics for surgical prophylaxis.

Hematology service was consulted considering that the patient experienced postoperative bleeding. Per hematology note, "Given no prior history of bleeding diathesis, it is unlikely that he has an underlying bleeding disorder. INR and PTT prior to operation were normal. If he had a bleeding disorder, differential may include von Willebrand's disease, dysfibrinogenemia, or platelet aggregation disorders. Acquired Factor XIII deficiency can also cause bleeding without affecting PTT but would be unusual."

Foley catheter was removed 9/30/2023,
in which the patient subsequently demonstrated ability to void. Further monitoring of patient demonstrated stable vitals, labs, and minimal output from surgical drain. The diet was serially advanced from clears to solid foods as per protocol, which was tolerated well. The patient did pass gas and demonstrate signs of bowel activity. The patient worked with nursing and did progressively demonstrate ability to ambulate. Pain control was adequate on PO pain medications. JP drain was removed before discharge. Vital Signs and Labs were reviewed prior to discharge and noted to be stable.

On day of discharge patient was deemed to be meeting discharge criteria and was therefore discharged in good and stable condition.

Drains:
None
Discharge Medications:
Bactrim DS 800 mg-160 mg oral tablet 1 tab(s), Oral, BID x 14 Days
Colace 100 mg oral capsule 100 mg = 1 cap(s), PRN, Oral, Daily
Norco 5 mg-325 mg oral tablet 1 tab(s), PRN, Oral, Q6hr # 7
Tylenol 500 mg oral tablet 500 mg, PRN, Oral, Q6hr


I reviewed the CURES 2.0 report for Mr. ______ on October 02, 2023 and did not identify a concerning activity or unexpected alert(s). My impression is that Mr. _____ is benefiting from the prescribed controlled medication(s) and that the benefits of continued
prescribing outweigh the risks.

Specific Controlled Prescription(s) Plan:
Continue present regimen. I Discussed with the patient risks, side effects and appropriate medications use.

Follow-up Plan: The patient will be following up on ____ 2023 with Dr. Doyle in outpatient urology clinic for postsurgical check. The patient will call to arrange this appointment.

Discharge Counseling: Patient was advised to seek medical attention or call with fever, nausea/vomiting, or intractable pain.
Contact numbers were provided in the event concerns were to arise.

Pathology:
REMOVAL AND REPLACEMENT OF INFLATABLE PENILE PROSTHESIS on 9/27/2023
A EXPLANTED PENILE PROSTHESIS:
- Medical device / hardware, per gross examination
Cesar Romero, PA-C
Discussed with resident Bajakian PGY-4
Discussed with Attending Dr. Loh-Doyle

ATTENDING ATTESTATION
Patient seen and examined. Patient is doing much better. The patient scrotum is soft. His blood levels have been stable. Vital signs have also been stable. He has been making good urine and been having bowel movements. His pain is well controlled. I thanked the patient for his patience throughout this hospitalization. I will see the patient back in 1 week. He was provided with my cell phone and he will let me know if his condition changes over the next few days. We will keep him on antibiotics as a prophylactic measure given the sizable hematoma he had.

[oldbeek]

Wow, that operation really went sideways. Glad to hear you are healing. USC/Keck, Dr LoDoyle and Dr Boyd are the best. The hospital and staff have saved my life. They are the best.

[Tmansdorfer]

Wow hope you are feeling better now. Glad the dr was able to bring you in and fix the issue.

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Thanks guys. I had my follow-up today and the healing is progressing quite fast. There's some slight hematoma left that Dr Loh-Doyle says will go away on its own. He's gonna see me again next week and just told me to stay on the antibiotics until they run out.

He said he talked to other high volume implanters in other parts of the country and asked if any of them have seen something like my case where a massive hematoma happened twice after an implant and they all said never. I'm apparently one of those freak medical cases where there's no explanation for it as nobody has a clue what could have caused it.

Wow hope you are feeling better now. Glad the dr was able to bring you in and fix the issue.

Wow, that operation really went sideways. Glad to hear you are healing. USC/Keck, Dr LoDoyle and Dr Boyd are the best. The hospital and staff have saved my life. They are the best.